髕上入路髓內釘治療脛骨干骨折的研究進展

陳水林 孫貴才

髕上入路髓內釘治療脛骨干骨折的研究進展

陳水林 孫貴才

脛骨骨折；骨折固定術，內；髓內釘；髕上入路；綜述

脛骨干骨折是四肢骨折中最為常見的一種[1]，約占全身骨折的 13.7%[2]。由于髓內釘具有微創(chuàng)、固定強度高、術后并發(fā)癥及再手術率低，目前成為脛骨干骨折的首選治療方案[3-6]。與傳統(tǒng)入路 ( 髕韌帶及髕韌帶旁入路 ) 相比，髕上入路脛骨髓內釘?shù)闹萌刖哂幸撞僮?、適應證更廣及術后并發(fā)癥發(fā)生率更低等優(yōu)勢[7-13]。筆者就近年來髕上入路髓內釘固定治療脛骨干骨折安全性的研究進展及其與傳統(tǒng)入路的對比研究作一綜述，為今后相關研究提供參考。

一、髕上入路脛骨髓內釘固定治療脛骨干骨折的安全性

髕上入路髓內釘固定治療脛骨干骨折最早由 Cole[14]提出，通過分析 1 例 80 歲脛骨干骨折患者病情最后選擇髕上入路髓內釘固定治療并取得理想的術后效果。有研究指出髕上入路是半伸膝位的一種改良的脛骨髓內釘手術入路，具有手術時間短，術后膝關節(jié)疼痛發(fā)生率低，骨折畸形愈合較少見等優(yōu)點[10-12]。付備剛等[15]指出髕上入路脛骨髓內釘內固定治療脛骨干骨折具有復位固定操作簡單、術中透視方便和術后并發(fā)癥少等優(yōu)點，尤其適用于近遠干骺端、多節(jié)段、小腿軟組織條件差及合并同側股骨骨折等特殊類型脛骨骨折的手術治療。但有反對者認為髕上入路脛骨髓內釘置入會增加髕股關節(jié)面壓力導致髕股關節(jié)面損傷，同時有可能損傷膝關節(jié)內重要軟組織結構及增加關節(jié)內感染的風險。Glebke 等[16]通過一具尸體研究發(fā)現(xiàn)髕上入路髓內釘固定治療脛骨干骨折時髕股關節(jié)面的壓力為 3.83×103kPa ( 1 kPa＝7.52 mm Hg )，低于造成軟骨細胞損傷標準的 4.5×103kPa，故得出髕上入路脛骨髓內釘并不會造成髕股關節(jié)面的損傷的結論。這結論在 Eastman等[17]的尸體研究中也得到證實。同樣，Gaines 等[18]研究發(fā)現(xiàn)髕上入路脛骨髓內釘不僅不會增加髕股關節(jié)面損傷的風險，而且膝關節(jié)重要軟組織結構損傷發(fā)生率更低。Beigang[19]通過 23 例髕上入路髓內釘固定治療脛骨干骨折患者并平均隨訪 15.5 個月后得出髕上入路脛骨髓內釘治療脛骨干骨折是安全、有效、利于早期康復并且無不良并發(fā)癥的結論，同時，Mitchell 等[20]指出髕上入路脛骨髓內釘?shù)闹萌氩⒉粫黾雨P節(jié)內感染的風險。

二、髓內釘固定治療脛骨干骨折髕上入路與傳統(tǒng)入路的對比

髓內釘固定治療脛骨干骨折髕上入路與傳統(tǒng)入路的對比主要有術中指標 ( 手術時間、術中 X 線放射時間、出血量 ) 及術后評分及并發(fā)癥發(fā)生率等方面。

1. 術中指標：鞏金鵬等[21]通過臨床研究指出兩種入路方式在手術時間、住院天數(shù)及術中出血量的比較中，差異無統(tǒng)計學意義；Courtney 等[22]通過隨機對照實驗發(fā)現(xiàn)，兩種入路方式在手術時間上差異無統(tǒng)計學意義，但髕上入路能明顯減少術中 X 線放射時間，且差異有統(tǒng)計學意義；Sun 等[23]通過隨機對照實驗指出兩種入路方式在手術時間、住院天數(shù)及術中出血量的比較中的差異無統(tǒng)計學意義，同時證實了髕上入路能明顯減少術中 X 線放射時間；同樣傅升培[24]通過隨機對照實驗對 98 例脛骨骨折患者分析指出兩種入路方式在手術時間、住院天數(shù)及術中出血量的比較中的差異無統(tǒng)計學意義；王等[25]通過回顧 68 例脛骨干骨折患者病例后分析指出髕上入路能明顯減少術中出血量及 X 線放射時間。

2. 術后評分：鞏金鵬等發(fā)現(xiàn)術后 24 周髕上入路較傳統(tǒng)入路優(yōu)良率高、髕上入路具有更高的 Lysholm 膝關節(jié)評分及術后患側膝前疼痛發(fā)生率更低，差異均有統(tǒng)計學意義；Sun 等通過隨機對照實驗證實了術后 24 周髕上入路具有更高的 Lysholm 膝關節(jié)評分，同時髕上入路具有更高的 SF-36 physical 和更低 VAS 評分，差異均有統(tǒng)計學意義，但 ROM 及 SF-36 physical 差異無統(tǒng)計學意義；Courtney 等發(fā)現(xiàn)兩種入路方式在術后 Oxford Knee Score 比較中，差異無統(tǒng)計學意義；傅升培發(fā)現(xiàn)術后 9 個月髕上入路組患者膝關節(jié) HSS 評分及 Lysholm 評分均優(yōu)于髕下入路組，差異有統(tǒng)計學意義；同時王等也發(fā)現(xiàn)術后 9 個月髕上入路具有更高的膝關節(jié) HSS 評分及 Johner-Wruhs 評分，差異均有統(tǒng)計學意義。

3. 術后并發(fā)癥：( 1 ) 慢性膝前區(qū)疼痛是傳統(tǒng)入路脛骨髓內釘術后最常見并發(fā)癥，病因不明，有研究指出，可能主要與髕韌帶完整性破壞、膝關節(jié)內結構損傷、隱神經髕下支損傷等因素有關[26-28]。孫和炎等發(fā)現(xiàn)髕上入路脛骨髓內釘術后膝關節(jié)前區(qū)疼痛發(fā)生率不足 5%；解冰等[29]采用髕上入路髓內釘固定治療脛骨近端骨折患者 16 例，隨訪2 年未出現(xiàn)膝關節(jié)疼痛；Courtney、Sun、Chan、王及王惠等[22-23,25,30-31]分別通過髕上入路及傳統(tǒng)入路對比發(fā)現(xiàn)，髕上入路術后膝關節(jié)前區(qū)疼痛發(fā)生率低，差異有統(tǒng)計學意義。( 2 ) 骨折術后成角畸形 脛骨近端 1 / 3 骨折及脛骨多段骨折，傳統(tǒng)入路脛骨髓內釘植入時，患膝需過曲位，由于髕腱的牽拉及骨折端的不穩(wěn)定，使得復位及固定困難，術后容易造成成角畸形[32-33]。Courtney 等發(fā)現(xiàn)髕上入路可以減少矢狀面成角，差異有統(tǒng)計學意義；Avilucea 等[34]同樣指出髕上入路可以減少冠狀面及矢狀面成角，與傳統(tǒng)入路相比，差異有統(tǒng)計學意義。

綜上所述，脛骨干骨折常由高能量損傷所致，由于脛骨前方肌肉組織較少，暴力損傷后容易造成開放性骨折，軟組織損傷、污染等，不僅影響傳統(tǒng)入路開口，而且增加切口不愈合、感染的風險[35]，髕上入路是一個很好的選擇方案。同時，與傳統(tǒng)入路比較，髕上入路具有操作方便，術中放射時間短，術后并發(fā)癥發(fā)生率少及優(yōu)良率高等優(yōu)勢。但髕上入路植入髓內釘經哪種手術方式移除仍具有爭議，同時需要外科醫(yī)生操作熟練，避免髕股關節(jié)面損傷，再加上手術費用貴，患者不容易接受。目前仍需要更多的大型對比性研究來給臨床一個合理的建議，但從臨床滿意效果來講，髕上入路脛骨髓內釘值得在臨床上推廣使用。

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Research progress of suprapatellar approach with intramedullary nails for the treatment of tibia shaft fractures

CHEN Shui-lin, SUN Gui-cai. Department of Orthopedics, the fourth Hospital affiliated to Nanchang University,Nanchang, Jiangxi, 330000, China

SUN Gui-cai, Email: 13657000633@139.com

s】 Tibia fracture is the most common one among the long bone fractures. The treatment included open reduction and internal fixation ( ORIF ), minimally invasive plate osteosynthesis ( MIPO ), external fixator and intramedullary nailing ( IMN ). The technology of tibia intramedullary nailing was first put forward by Kuntscher.Intramedullary nailing ( IMN ) was preferred for most tibia shaft fractures, because of its advantage of minimal surgical dissection with appropriate preservation of blood supply, with fewer complications and re-operations. Classic approach of tibia intramedullary nailing was conducted either through or near the patellar tendon. Both technologies required a hyperflexed knee, which was easy to cause the proximal tibia fracture angulation deformity. The rate of chronic anterior knee pain was reported varying from 10% to 70%, with an average of 50%. A semi-extended suprapatellar approach was described, with advantages of shorter operation time, lower incidence rate of postoperative knee pain and fracture malunion. However, some considered the suprapatellar approach may increase the patellofemoral joint surface pressure which may cause the damage of patellofemoral joint surface, or injurg of important soft tissue structures such like meniscus within the knee joint. This review summarizes the researches on the suprapatellar approach with intramedullary nails for the treatment of tibia shaft fractures.

Tibial fractures; Fracture fixation, internal; Intramedullary nailing; Suprapatellar approach;Review

10.3969/j.issn.2095-252X.2017.11.010

R683.4, R687.3

330000 南昌大學第四附屬醫(yī)院骨科

孫貴才，Email: 13657000633@139.com

2016-12-31 )

( 本文編輯：李慧文 )